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E-Referral Form (Doctor to Complete)

Patient Details

First Name

Last Name

Date of Birth

Phone Number

Email

Address

Street address

City

State

Postcode

Patient Information

Height (cm)

Weight (kg)

BMI (if known)

Medicare & Healthcare Information

Appointment Type

Select *

Medicare NumberHealthcare CardPension Card

Please select *

GastroscopyColonoscopyBoth Gastroscopy & ColonoscopyConsult

Please review Surfcoast Endoscopy Exclusion Criteria (SEEC) to check for risks and outline these (if applicable) below

https://www.surfcoastendoscopy.com/for-doctors/

Symptoms & Investigations (Tick where applicable, add comment if "Yes")

Anaemia and/or Fe Deficiency

Yes

Rectal bleeding, duration

Yes

Unexplained weight loss

Yes

Palpable Mass (Abdominal or Rectal)

Yes

Positive FOBT

Yes

Diarrahoea (stool culture negative), duration

Yes

Change in usual bowel habit

Yes

Unexplained abdominal pain > 6 weeks

Yes

Abnormal Imaging

Yes

Hb

Yes

Calprotectin

Yes

Ferritin

Yes

MCV

Yes

Coeliac Serology

Yes

(If 'Yes' to any of the above, provide comments)

Clinical Indicators (Tick or comment as applicable)

Further Comments

Please ensure a list of all current medications is attached to this referral. Referrals without this information will not be accepted.

Supporting Documents

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Doctor Confirmation

First Name

Last Name

Provider Number

Phone

Address

Post Code

I have reviewed the Exclusion Protocol and can confirm that *

The patient has a risk identified in the Surfcoast Endoscopy Exclusion Criteria (SEEC) and therefore requires a PAC to be arranged by SES period to a procedure being booked.The patient does not have a risk identified in the SEEC.

I have reviewed the SurfCoast Endoscopy Privacy Policy (SEPP) at www.surfcoastendoscopy.com/privacy and have obtained consent from my patient to provide this information here. *

Date *

Doctor's Signature *

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